2021 Employee Benefit Enrollment

Let's start with the basics. What's your name?*
First NameLast Name
What's your birth date?*
How old will you be on January 1st, 2021*
You're nailing this form completion thing! So, what's your current address?*
Street Address
Street Address Line 2
CityState
Zip Code
What's your email address?*
example@example.com
Medical, Dental, Vision Benefit Enrollment
Full-time, regular status employees working at least 1,560 hours per year are eligible to participate in Colonial's medical, vision, and dental insurance plans.
Would you like to enroll in or waive benefit coverage for 2021?*
I don't want to make any changes from what I selected last year.I want to change some things from last year. Show me all of my options and I'll select what I want to do.Waive medical, dental, and vision. I understand that if I choose to waive now, but have a qualifying life cycle event in 2021, I will have the option to change my election within 30 days of said event.
Please select your preferred level of medical coverage.*
Employee onlyEmployee + Child(ren)Employee + SpouseFamilyWaive medical coverage
I see you elected to enroll your spouse in Colonial's coverage.*
My spouse is not employed and therefore has no other options for medical coverage.My spouse is not eligible for medical coverage through their employer.My spouse is eligible for coverage through their place of employment, however we prefer to enroll in and pay for Colonial's coverage for him/her instead of or in addition to said coverage. I acknowledge, understand, and agree that the full cost of Colonial's medical coverage for my spouse will be deducted from my paycheck every pay period.
Okay, now how would you like to enroll for dental and vision coverage?*
Employee Employee + Spouse Employee + Child(ren) Family Waive
Dental
Vision
Flexible Spending Accounts
A Flexible Spending Account (FSA), is a voluntary, tax-free way for employees to save for qualified medical expenses, dependent care, and/or non-employer sponsored premiums during a plan year. Yep, it's pretty cool and it's awesome to have money already set aside for when you need it.
Colonial's 403B Plan
Colonial will make employer contributions into your 403B retirement account at a rate of 1/3 up to the first 6% of your annual salary that you choose to contribute. It's an easy way to save for retirement and you can get FREE MONEY!
Would you like to enroll in or continue 403B contributions?*
YESNO
403B Enrollment
Using traditional symbols (% or $), please indicate if this is a percentage or actual dollar amount you would like withheld every pay period.
Would you like this to be a pre-tax or Roth (after tax) 403B contribution?
Pre-taxRoth (after tax)
Well, that's it for now.
If you're ready, click submit, sit back, and bask in the sense of accomplishment.
I'll email you a copy of your submission (yep, you're welcome😁).
Should be Empty:

	Employee	Employee + Spouse	Employee + Child(ren)	Family	Waive
Dental
Vision

Medical, Dental, Vision Benefit Enrollment

Flexible Spending Accounts

Colonial's 403B Plan